Provider Demographics
NPI:1598235889
Name:MOORE, JACQUELINE MARIE (MSN, PMHNP-BC, RN)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:MARIE
Last Name:MOORE
Suffix:
Gender:F
Credentials:MSN, PMHNP-BC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:701 NE 136TH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-6937
Mailing Address - Country:US
Mailing Address - Phone:360-322-4711
Mailing Address - Fax:360-583-6404
Practice Address - Street 1:701 NE 136TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-6937
Practice Address - Country:US
Practice Address - Phone:360-322-4711
Practice Address - Fax:360-583-6404
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-29
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60911808363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty